| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Date/Time of Birth | 12/23/2009 11:05 |
| Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT |
| Patient Phone | (203)555-1212 |
| Description |
|---|
The Immunization Registry returns an Evaluated History and Forecast (Z42) to the EMR in response to the query for patient (Juana Mariana Gonzales). The provider reviews the immunization history from the registry and compares to the immunization history in the EMR. The provider reconciles the information from these sources, importing information known only to the registry, retaining information that is more accurately reflected in the local EMR: The physician accesses the record for Juana Mariana Gonzales and:
• Reconciles the EHR vaccine history with the history retrieved from the registry:
o Accepts new vaccines from the registry data
o If the EHR does not already flag the first MMRV as invalid, the provider updates the first MMRV to indicate it is “invalid” as it was given too early (as notified by the registry)
o Retains the local history for influenza and polio vaccines that are not included in the registry report.
|
| Comments |
|---|
No Comments |
| PreCondition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR. |
| PostCondition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient’s local immunization history and include the time of the update and the source of the new information. Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).
|
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. |
| Notes to Testers |
|---|
No Note |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Patient Juana Mariana Gonzales | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Gonzales | |
| Date of Birth | 12/23/2009 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2009 | |
| Date/Time Administration-End | 11/23/2009 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, unspecified formulation | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/15/2010 | |
| Date/Time Administration-End | 01/15/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/30/2010 | |
| Date/Time Administration-End | 10/30/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2011 | |
| Date/Time Administration-End | 02/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2010 | |
| Date/Time Administration-End | 02/21/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/21/2010 | |
| Date/Time Administration-End | 01/21/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2011 | |
| Date/Time Administration-End | 02/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2010 | |
| Date/Time Administration-End | 09/25/2010 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/27/2010 | |
| Date/Time Administration-End | 10/27/2010 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2011 | |
| Date/Time Administration-End | 10/02/2011 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 04/04/2012 | |
| Date/Time Administration-End | 04/04/2012 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2011 | |
| Date/Time Administration-End | 11/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2012 | |
| Date/Time Administration-End | 05/23/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | measles, mumps, rubella, and varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/23/2010 | |
| Date/Time Administration-End | 10/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | measles, mumps, rubella, and varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2012 | |
| Date/Time Administration-End | 11/22/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 05/22/2010 | |
| Earliest Date to Give | 05/22/2010 | |
| Latest Date to Give | 05/22/2011 | |
| Date When Vaccine Overdue | 05/23/2011 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2015 | |
| Earliest Date to Give | 09/01/2015 | |
| Latest Date to Give | 01/31/2016 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
If the EHR does not already flag the first MMRV as invalid, the provider updates the first MMRV to indicate it is “invalid” as it was given too early (as notified by the registry) |
| Comments |
|---|
If the EMR already recognizes the dose as invalid, then this step may be skipped. |
| PreCondition |
|---|
MMRV status indicates that the first MMRV dose is valid. |
| PostCondition |
|---|
MMRV status for the first MMRV dose administered on 10/23/2010 is set to invalid. |
| Test Objectives |
|---|
dose validity is an important aspect of: Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.
|
| Evaluation Criteria |
|---|
Vendor is able to record that the vaccination dose is invalid with a reason that it was given too early |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
The physician accesses the record for Juana Mariana Gonzales and: • Displays the registry forecast which includes the need for a second, valid MMRV vaccine and also the need for influenza and polio vaccines (since the registry has no information about them) |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR. |
| PostCondition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, ideal date, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. Verify that All forecast vaccines and dates returned by the registry are displayed to the user. |
| Notes to Testers |
|---|
No Note |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Patient Juana Mariana Gonzales | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Gonzales | |
| Date of Birth | 12/23/2009 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2009 | |
| Date/Time Administration-End | 11/23/2009 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, unspecified formulation | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/15/2010 | |
| Date/Time Administration-End | 01/15/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep B Peds NOS | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/30/2010 | |
| Date/Time Administration-End | 10/30/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2011 | |
| Date/Time Administration-End | 02/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2010 | |
| Date/Time Administration-End | 02/21/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | SC | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/21/2010 | |
| Date/Time Administration-End | 01/21/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2010 | |
| Date/Time Administration-End | 03/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2010 | |
| Date/Time Administration-End | 05/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2011 | |
| Date/Time Administration-End | 02/21/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2010 | |
| Date/Time Administration-End | 01/22/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2010 | |
| Date/Time Administration-End | 09/25/2010 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/27/2010 | |
| Date/Time Administration-End | 10/27/2010 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2011 | |
| Date/Time Administration-End | 10/02/2011 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 04/04/2012 | |
| Date/Time Administration-End | 04/04/2012 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2011 | |
| Date/Time Administration-End | 11/23/2011 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2012 | |
| Date/Time Administration-End | 05/23/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | measles, mumps, rubella, and varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/23/2010 | |
| Date/Time Administration-End | 10/23/2010 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMRV | |
| Vaccine Administered | measles, mumps, rubella, and varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2012 | |
| Date/Time Administration-End | 11/22/2012 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 05/22/2010 | |
| Earliest Date to Give | 05/22/2010 | |
| Latest Date to Give | 05/22/2011 | |
| Date When Vaccine Overdue | 05/23/2011 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2015 | |
| Earliest Date to Give | 09/01/2015 | |
| Latest Date to Give | 01/31/2016 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 11/22/2013 | |
| Earliest Date to Give | 11/22/2013 | |
| Latest Date to Give | 11/22/2015 | |
| Date When Vaccine Overdue | 11/23/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
No Description |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| PostCondition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Gonzales) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
1. The user imports returned vaccinations as follows:
a. Vaccinations NOT imported:
hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 1/15/2010
measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 11/22/2012
VERIFY that the dose validity is marked as invalid
b. Vaccinations Imported:
hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 10/30/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2010,
Including adverse reaction 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2011
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 2/21/2011
poliovirus vaccine, inactivated (CVX 10) administered 1/22/2010
poliovirus vaccine, inactivated (CVX 10) administered 3/23/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 2/21/2011
rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/27/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2011
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2012
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2011
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2012
measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 11/22/2012
|
| Notes to Testers |
|---|
No Note |
| Description |
|---|
Once the vaccine history is reconciled in the EMR, the vaccine forecast is updated. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
EMR Vaccine History is Reconciled with Immunization History from the IIS (previous step 'Reconcile and import vaccinations from Evaluated History and Forecast returned by the Registry for Juana Mariana Gonzales'). |
| PostCondition |
|---|
An updated vaccine forecast based upon the reconciled vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: 1. Verify that the EMR does not include in reconciled vaccine forecast:
IPV due on 5/22/2010
2. Verify that the EMR includes in reconciled vaccine forecast:
IPV due on 11/22/2013
MMR due on 5/22/2011
Varicella due on 5/22/2011
influenza, unspecified formulation due on 10/21/2015
|
| Notes to Testers |
|---|
No Note |
| Description |
|---|
| No Description |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| No PreCondition |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
|
The physician accesses the record for Juana Mariana Gonzales and: • Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| PostCondition |
|---|
IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures). |
| Test Objectives |
|---|
Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record. |
| Evaluation Criteria |
|---|
EMR Records the following order information and Alert: Entered BY: Sandra Molina Ordering Provider: Frank Smith |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
|
The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother’s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
Prior Immunization History loaded and reconciled from the Immunization Registry. Order is attempted for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures. |
| PostCondition |
|---|
Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is permanent. |
| Test Objectives |
|---|
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria |
|---|
EMR documents the non-administration of the IPV due to the parental refulsal: |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
|
The nurse administers the the MMRV vaccine
|
| Comments |
|---|
No Comments |
| PreCondition |
|---|
|
Order is placed for MMRV vaccine. |
| PostCondition |
|---|
|
The MMRV vaccination is recorded in the EMR. |
| Test Objectives |
|---|
|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria |
|---|
EMR Records the following vaccine administration information: Entered BY: Sandra Molina [Y] Ordering Provider: Frank Smith [Y] |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
| The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| PreCondition |
|---|
| The vaccines for the visit have been administered. |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| PreCondition |
|---|
The vaccines for the visit have been administered. |
| PostCondition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes to Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address1 | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Description |
|---|
| No Description |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| No PreCondition |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | |||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Description |
|---|
Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
The vaccinations for the visit have been administered. |
| PostCondition |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| Test Objectives |
|---|
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. |
| Evaluation Criteria |
|---|
Verify that vendor can record the adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| PostCondition |
|---|
The adverse reaction has been transmitted to the IIS. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes to Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address1 | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| Description |
|---|
| No Description |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| No PreCondition |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | |||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||